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Abstract Background Endometriosis is a prevalent disease among women worldwide, including the Middle East. Insufficient knowledge about the disease causes delayed diagnosis which could result in major complications, particularly infertility. Thus, being aware of the symptom’s aids in prompt diagnosis and treatment. Furthermore, no research has been done in Lebanon to assess the Lebanese women’s knowledge about endometriosis. Aim To determine the understanding and concerns of Lebanese women about endometriosis which aids in identifying knowledge gaps and misconceptions so that they can be addressed. Methods A cross-sectional study was conducted between February and March 2024 among Lebanese females, who completed the authors’ online questionnaire assessing knowledge and concern about endometriosis and its associated symptoms, Multivariable logistic regression analysis was used to explore the relationship between score of knowledge and different characteristics of patients. Results A survey of 725 Lebanese women (mean age 32.5 years, SD = 9.5) revealed low knowledge (25.9%) about endometriosis origin, symptoms, and treatment. Over 60% were unaware of endometriosis symptoms, while 9.9% mistakenly believed menstrual cramps indicated the disease. Younger age (

Massive rotator cuff tears constitute approximately 20% of all rotator cuff tears. Poor tissue quality or significant retraction can lead to failure of the repair. The anterior rotator cuff cable is essential in transmitting force to the proximal humerus and serves as the main load-bearing structure within the supraspinatus. Utilizing the long head of the biceps tendon (LHBT) for anterior cable reconstruction in the setting of rotator cuff tears, known as biceps augmentation, has the potential for improved biomechanical and healing properties. Importantly, the proximal LHBT remains attached to the superior glenoid labrum, serving as a viable collagen scaffold, a structural scaffold for the cable, and potentially as a conduit for living tenocytes to migrate into the hypovascular region of the rotator cuff, promoting repair healing. Similar methods utilize the transfer of the intact LHBT into the rotator cuff without a biceps tenodesis. While this accomplishes the aforementioned goals, it may create a source of biceps pain in these patients, and it changes the length–tension relationship of the LHBT distal to the transfer site. In this technical note, we detail an anterior cable reconstruction employing an autologous LHBT to reinforce a repaired massive rotator cuff tear with concurrent subpectoral tenodesis of the LHBT to achieve goals of 1) rotator cuff augmentation and grafting and, importantly and 2) securing the LHBT in a subpectoral position to mitigate pain and maintain supination strength while maintaining the anatomic length–tension relationship of the biceps. We feel this approach is superior in ensuring sufficient tendon is retained for an effective transfer and allows for a subpectoral tenodesis to prevent biceps symptoms.

Pathology of the long head of the biceps tendon is commonly associated with massive rotator cuff tears (MRCTs), which account for roughly one third of all rotator cuff tears. Treatment options for this condition include tenotomy, tenodesis, augmentation, and the use of the tendon as a graft for partial superior capsule reconstruction. Augmentation and superior capsular reconstruction are evolving techniques in the management of MRCTs. However, similar to the lack of consensus on the treatment of MRCTs, there are no clear guidelines for the management of concurrent biceps tendon pathology.

Abstract Deep neural networks (DNNs) are fundamental to modern applications like face recognition and autonomous driving. However, their security is a significant concern due to various integrity risks, such as backdoor attacks. In these attacks, compromised training data introduce malicious behaviors into the DNN, which can be exploited during inference or deployment. This paper presents a novel game-theoretic approach to model the interactions between an attacker and a defender in the context of a DNN backdoor attack. The contribution of this approach is multifaceted. First, it models the interaction between the attacker and the defender using a game-theoretic framework. Second, it designs a utility function that captures the objectives of both parties, integrating clean data accuracy and attack success rate. Third, it reduces the game model to a two-player zero-sum game, allowing for the identification of Nash equilibrium points through linear programming and a thorough analysis of equilibrium strategies. Additionally, the framework provides varying levels of flexibility regarding the control afforded to each player, thereby representing a range of real-world scenarios. Through extensive numerical simulations, the paper demonstrates the validity of the proposed framework and identifies insightful equilibrium points that guide both players in following their optimal strategies under different assumptions. The results indicate that fully using attack or defense capabilities is not always the optimal strategy for either party. Instead, attackers must balance inducing errors and minimizing the information conveyed to the defender, while defenders should focus on minimizing attack risks while preserving benign sample performance. These findings underscore the effectiveness and versatility of the proposed approach, showcasing optimal strategies across different game scenarios and highlighting its potential to enhance DNN security against backdoor attacks.

Abstract Stereo-electroencephalography (SEEG) is the gold standard to delineate surgical targets in focal drug-resistant epilepsy. SEEG uses electrodes placed directly into the brain to identify the seizure-onset zone (SOZ). However, its major constraint is limited brain coverage, potentially leading to misidentification of the ‘true’ SOZ. Here, we propose a framework to assess adequate SEEG sampling by coupling epileptic biomarkers with their spatial distribution and measuring the system’s response to a perturbation of this coupling. We demonstrate that the system’s response is strongest in well-sampled patients when virtually removing the measured SOZ. We then introduce the spatial perturbation map, a tool that enables qualitative assessment of the implantation coverage. Probability modelling reveals a higher likelihood of well-implanted SOZs in seizure-free patients or non-seizure free patients with incomplete SOZ resections, compared to non-seizure-free patients with complete resections. This highlights the framework’s value in sparing patients from unsuccessful surgeries resulting from poor SEEG coverage.

BackgroundHealth system reform initiatives have increasingly embraced decentralization as a key trend. The implementation process and its outcomes are influenced by a myriad of factors, including economic forces, political dynamics, and ideological factors. Comprehending and carefully examining the implementation phase of decentralization and its consequences to achieve desired outcomes is crucial. Notably, this phase is often considered the weakest aspect of policy reforms, especially in developing countries. Therefore, this study aimed to explore and analyze the implementation phase of decentralization and its implications as essentials for achieving intended goals. The study objectives evolved around examining the entire decentralization as a multifaceted social and political process in Khartoum State, Sudan, from its early stages of decision-making, policy formulation, and implementation process and the influencing contextual factors.MethodsThis study was an exploratory qualitative study that employed in-depth interviews to gather perspectives of healthcare providers and policymakers, semi-structured observations, and thematic analysis. The study utilized Grindle’s framework for analysis.FindingsThis study revealed a political nature of decision-making, with a top–down approach to the implementation, which also lacked stakeholder involvement. It showed a lack of transparency, official documentation, and proper handover procedures from the Ministry of Health to the devolved hospitals during the implementation process. A conflict of interest between the federal and the state level was also reported. It is important to note that this process occurred within the context of structural adjustment program (SAP) schemes, which had already empowered the private sector in Sudan.ConclusionThis study documented the implementation process of decentralization of health services and its influencing factors. The study recommended reforming the decentralization policy through consultative stakeholder involvement and by implementing a concurrent responsibility paradigm that divides authority between the federal and state levels.

Introduction: proteinuria is associated with poor allograft and patient survival in kidney transplant recipients (KTRs). This study aims to investigate the prevalence and risk factors of proteinuria in KTRs and its impact on kidney function during the first two years after kidney transplantation (KT). Materials and methods: 200 KTRs were included in this retrospective cohort study from living donors, performed in two University hospitals in Syria, from January 2018 to March 2021. Demographic and immunological characteristics were analyzed depending on the 24 h urine protein (Up) excretion that was classified into three groups: Up I (150–500 mg/day), Up II between (0.5–1 g/day), and Up III (>1 g/day). Results: Up was increased subsequently as the transplant progressed, where the greatest excretion of the Up was reported 2 years after KT. At 6 months after KT; the cold ischemic time (CIT), serum creatinine (Cr), using angiotensin-converting enzyme inhibitors (ACEIs)/ angiotensin II receptor blockers (ARBs), and GFR showed strong significant differences between Up groups (P = 0.00003, 0.0001, 0.00001, and 0.026; respectively). The CIT and Cr were higher in the Up III group compared to Up I and UP II groups. At 12 months after KT; Cr, using ACEIs/ARBs, and GFR showed strong significant differences between Up groups (P = 0.00009,

Abstract Alterations in gut microbiota composition are suggested to contribute to cardiometabolic diseases, in part by producing bioactive molecules. Some of the metabolites are produced by very low abundant bacterial taxa, which largely have been neglected due to limits of detection. However, the concentration of microbially produced metabolites from these taxa can still reach high levels and have substantial impact on host physiology. To explore this concept, we focused on the generation of secondary bile acids by 7α-dehydroxylating bacteria and demonstrated that addition of a very low abundant bacteria to a community can change the metabolic output dramatically. We show that Clostridium scindens converts cholic acid into the secondary bile acid deoxycholic acid (DCA) very efficiently even though the abundance of C. scindens is low, but still detectable by digital droplet PCR. We also show that colonization of germ-free female mice with a community containing C. scindens induces DCA production and affects host metabolism. Finally, we show that DCA correlates with impaired glucose metabolism and a worsened lipid profile in individuals with type 2 diabetes, which implies that this metabolic pathway may contribute to the development of cardiometabolic disease.

Abstract Background Potato serves as a major non-cereal food crop and income source for small-scale growers in Punjab, Pakistan. Unfortunately, improper fertilization practices have led to low crop yields, worsened by challenging environmental conditions and poor groundwater quality in the Cholistan region. To address this, we conducted an experiment to assess the impact of two fertilizer application approaches on potato cv. Barna using plant growth-promoting bacteria (PGPB) coated biofertilizers. The first approach, termed conventional fertilizer application (CFA), involved four split applications of PGPB-coated fertilizers at a rate of 100:75 kg acre–1 (N and P). The second, modified fertilizer application (MFA), employed nine split applications at a rate of 80:40 kg acre–1. Results The MFA approach significantly improved various plant attributes compared to the CFA. This included increased plant height (28%), stem number (45%), leaf count (46%), leaf area index (36%), leaf thickness (three-folds), chlorophyll content (53%), quantum yield of photosystem II (45%), photosynthetically active radiations (56%), electrochromic shift (5.6%), proton flux (24.6%), proton conductivity (71%), linear electron flow (72%), photosynthetic rate (35%), water use efficiency (76%), and substomatal CO2 (two-folds), and lowered non-photochemical quenching (56%), non-regulatory energy dissipation (33%), transpiration rate (59%), and stomatal conductance (70%). Additionally, the MFA approach resulted in higher tuber production per plant (21%), average tuber weight (21.9%), tuber diameter (24.5%), total tuber yield (29.1%), marketable yield (22.7%), seed-grade yield (9%), specific gravity (9.6%), and soluble solids (7.1%). It also reduced undesirable factors like goli and downgrade yields by 57.6% and 98.8%, respectively. Furthermore, plants under the MFA approach exhibited enhanced nitrogen (27.8%) and phosphorus uptake (40.6%), with improved N (26.1%) and P uptake efficiency (43.7%) compared to the CFA approach. Conclusion The use of PGPB-coated N and P fertilizers with a higher number of splits at a lower rate significantly boosts potato production in the alkaline sandy soils of Cholistan.

Abstract In recent decades, numerous studies have examined the effects of climate change on the responses of plants. These studies have primarily examined the effects of solitary stress on plants, neglecting the simultaneous effects of mixed stress, which are anticipated to transpire frequently as a result of the extreme climatic fluctuations. Therefore, this study investigated the impact of applied chitosan on boosting the resistance responses of peanuts to alkali and mixed drought-alkali stresses. Peanuts were grown in mid-alkaline soil and irrigated with full irrigation water requirements (100%IR), represented alkali condition (100% IR × alkali soil) and stress conditions (70% IR × alkali soil—represented mixed drought-alkali conditions). Additionally, the plants were either untreated or treated with foliar chitosan. The study evaluated various plant physio-chemical characteristics, including element contents (leaves and roots), seed yield, and irrigation water use efficiency (IWUE). Plants that experienced solitary alkali stress were found to be more vulnerable. However, chitosan applications were effective for reducing (soil pH and sodium absorption), alongside promoting examined physio-chemical measurements, yield traits, and IWUE. Importantly, when chitosan was applied under alkali conditions, the accumulations of (phosphorus, calcium, iron, manganese, zinc, and copper) in leaves and roots were maximized. Under mixed drought-alkali stresses, the results revealed a reduction in yield, reaching about 5.1 and 5.8% lower than under (100% IR × alkali), in the first and second seasons, respectively. Interestingly, treated plants under mixed drought-alkali stresses with chitosan recorded highest values of relative water content, proline, yield, IWUE, and nutrient uptake of (nitrogen, potassium, and magnesium) as well as the lowest sodium content in leaves and roots. Enhances the accumulation of (N, K, and Mg) instead of (phosphorus, calcium, iron, manganese, zinc, and copper) was the primary plant response to chitosan applications, which averted severe damage caused by mixed drought-alkali conditions, over time. These findings provide a framework of the nutrient homeostasis changes induced by chitosan under mixed stresses. Based on the findings, it is recommended under mixed drought-alkali conditions to treat plants with chitosan. This approach offers a promising perspective for achieving optimal yield with reduced water usage.

Background: Thoracic aortic dissection (TAD) is an uncommon complication in patients with Tetralogy of Fallot (TOF). Information concerning risk factors for TAD in patients with TOF is very limited. Methods: We report a case of Stanford type A TAD in a female patient with previously repaired TOF. Whole exome sequencing (WES); Novogene UK, Agilent V6 capture kit, Illumina HiSeq 100x depth) was performed to identify genetic variants in genes known to be associated with TAD. A systematic literature review was performed in the NCBI PubMed database to identify case reports of TAD in patients with TOF. Results: The patient was a 31-year-old female who developed Stanford type A aortic dissection having had TOF repair at the age of four years. The thoracic aorta was only minimally dilated (sinus of Valsalva 43 mm) on clinical review 16 months prior to TAD. Of note the patient had completed pregnancy 5 months prior to the dissection. There were no other high-risk features predisposing to TAD. WES identified rare genetic variant in a gene previously associated with TAD: MYLK (p.Arg1405His). The literature review identified nine other case reports of TAD in patients with TOF. The reported patients, had no clinical characteristics that distinguished them from the wider population of patients with TOF. Conclusions: The presence of a rare genetic variant in MYLK is a plausible explanation for the clinical presentation. The variant will need further verification to confirm pathogenicity. Pathogenic MYLK variants have been previously reported in context of dissection with minimally dilated aortas.

Summary: Background: In industrialized countries, the incidence of inflammatory bowel disease (IBD) appears stabilized. This study examined the incidence and phenotype of IBD in Northern France over a 30-year period. Methods: Including all IBD patients recorded in the EPIMAD population-based registry from 1988 to 2017 in Northern France, we described the incidence and clinical presentation of IBD according to age, sex and time. Findings: A total of 22,879 incident IBD cases were documented (59% (n = 13,445) of Crohn’s disease (CD), 38% (n = 8803) of ulcerative colitis (UC), 3% (n = 631) of IBD unclassified (IBDU)). Over the study period, incidence of IBD, CD and UC was 12.7, 7.2 and 5.1 per 105 person-years, respectively. The incidence of CD increased from 5.1/105 in 1988–1990 to 7.9/105 in 2015–2017 (annual percent change (APC): +1.9%, p

Cardiovascular diseases (CD), or heart diseases (HD), lead to approximately 17.9 million deaths each year, constituting 32% of global fatalities. Early detection and appropriate treatment of HDs can significantly reduce mortality rates, with timely intervention before disease progression enhancing treatment efficacy. Early detection is achievable through routine medical examinations and monitoring key symptoms, such as cholesterol levels, blood pressure variations, diabetes and obesity. This manuscript introduces a heart disease prediction (HDP) model designed to identify the presence of HDs at an initial stage. The study explores three methodologies: (a) traditional convolutional neural network (CNN), (b) CNN augmented with flower pollination optimization (FPO) algorithm and (c) CNN combining Teaching Learning-Based Optimization (TLBO) coupled with genetic algorithm (GA) for refined HDP. The model progresses through stages of data preparation, model construction, training and evaluation. The traditional CNN model resulted an accuracy of 81.97%, precision of 84%, recall of 81% and F1-score of 83%. Incorporating the FPO algorithm, model’s performance is enhanced with accuracy, precision, recall, F1-score of 85.25%, 90%, 81% and 85%, respectively. Further, optimized with TLBO and GA hybrid approach lead to superior performance with an accuracy, precision, recall, F1-score of 86.9%, 87.5%, 87.5% and 87.5%, respectively. The area under curve (AUC) for the receiver operating characteristics (ROC) and precision–recall curve (PRC) highlights the performance of the proposed hybrid methodology. These outcomes underscore the effectiveness of merging bio-inspired algorithms with CNN for early stage HD prediction (HDP), offering significant advancements in healthcare diagnostics.

Abstract Introduction Dual eligible beneficiaries are a vulnerable population who often experience inferior access to care and outcomes compared to non‐dual eligible beneficiaries. The Oncology Care Model (OCM) is an alternative payment model that aims to improve coordination and quality of care in beneficiaries receiving chemotherapy and thus may improve care for dual eligible beneficiaries with cancer. Methods We used 100% Medicare claims data from 2014 through 2019 and included beneficiaries with bladder, breast, esophageal, colorectal, kidney, lung, pancreatic, or prostate cancer receiving chemotherapy. We constructed multivariable difference‐in‐differences regression models to evaluate the effect of OCM participation on healthcare utilization and quality of care at the end‐of‐life among dual eligible beneficiaries. We also compared healthcare utilization and quality of care outcomes to non‐dual eligible beneficiaries. Results We identified 3,043,944 episodes of care among 1,260,892 unique Medicare beneficiaries. Ten percent of all beneficiaries (n = 126,758) were dual eligible and 64,087 (22%) of episodes among dual eligible patients were in an OCM participating practice. We noted no effect of OCM participation on healthcare utilization or end‐of‐life quality of care for dual eligible beneficiaries. However, we observed higher rates of hospitalization, emergency department visits, intensive care unit stays, and a lower number of office visits among dual eligible beneficiaries compared to non‐dual eligible beneficiaries. Conclusions Participation in OCM was not associated with improvements in quality of care or healthcare utilization for dual eligible beneficiaries. Dual eligible beneficiaries experience lower quality of care across several measures compared to non‐dual eligible beneficiaries. Focused policies and incentives may be necessary to address disparities within emerging health reforms.

BackgroundArtificial intelligence, particularly chatbot systems, is becoming an instrumental tool in health care, aiding clinical decision-making and patient engagement. ObjectiveThis study aims to analyze the performance of ChatGPT-3.5 and ChatGPT-4 in addressing complex clinical and ethical dilemmas, and to illustrate their potential role in health care decision-making while comparing seniors’ and residents’ ratings, and specific question types. MethodsA total of 4 specialized physicians formulated 176 real-world clinical questions. A total of 8 senior physicians and residents assessed responses from GPT-3.5 and GPT-4 on a 1-5 scale across 5 categories: accuracy, relevance, clarity, utility, and comprehensiveness. Evaluations were conducted within internal medicine, emergency medicine, and ethics. Comparisons were made globally, between seniors and residents, and across classifications. ResultsBoth GPT models received high mean scores (4.4, SD 0.8 for GPT-4 and 4.1, SD 1.0 for GPT-3.5). GPT-4 outperformed GPT-3.5 across all rating dimensions, with seniors consistently rating responses higher than residents for both models. Specifically, seniors rated GPT-4 as more beneficial and complete (mean 4.6 vs 4.0 and 4.6 vs 4.1, respectively; P

Background: The rapid advancement of the digital revolution, normalization of portable smart gadgets, and internet-based communication have resulted in a perceptible shift and enhancement in human spine posture. They have also resulted however, in the emergence of health issues connected to the technique of usage. Neck pain, as well as other related symptoms, are the most commonly reported, as evidenced by the Coronavirus pandemic. People were urged to work from home when educational institutions and businesses were shut down. Students were given access to online learning facilities. Aim: The aim of this study is to demonstrate and clarify the increase in the number of young patients who suffer from neck pain and its associated symptoms; especially during the COVID 19 pandemic. The objective of this study is to investigate the impact of the excessive use of smart portable devices on neck pain and associated symptoms. This is most likely related to the incorrect posture of the neck, spine and body during utilization of these technologies. In addition, it aims to educate people about possible methods to prevent these medical morbidities. Methods: A cross-sectional study was conducted at Mediclinic City Hospital, Dubai Healthcare City, United Arab Emirates. Fifty-six patients were seen and evaluated as outpatients in the Neurosurgery clinic for neck pain. The Numerical Rating Pain Scale questionnaire (NMQ) was utilized to evaluate neck pain and other associated complaints such as back and musculoskeletal pain in general. The data was collected using a questionnaire with a 100% response rate from the patients. Cross tabulation and Chi Square analysis tool were designed to meet the study’s objective. Results: The findings show that smart phone and laptop use have significant effects on pain severity ranking among patients. For the factors “Time spent using smart phone/day” and Time spent using Laptop/day” were found to have a P value of 0.041 and 0.023; respectively. Conclusion: This research found a link between length of time spent using a mobile phone or laptop and the degree of neck discomfort.

Abstract Background Against the backdrop of Lebanon’s escalating multifaceted crisis which resulted in medication shortages for chronic diseases and unaffordable healthcare services, the current study endeavors to shed light on a critical yet overlooked facet of the Lebanese economic crisis– its profound impact on the health-seeking behaviors of patients with hypertension and diabetes mellitus. Methods An exploratory cross-sectional study based on an online questionnaire was conducted on 156 adult Lebanese citizens diagnosed medically with either hypertension or diabetes. We gathered sociodemographic characteristics and healthcare-related challenges faced during the economic crisis. We also assessed stress levels using the Depression Anxiety Stress Scale (DASS-21). Descriptive and bivariate analyses were done using SPSS version 26. Results The mean age of the population was 49.8 ± 17.7 years old, 51.6% were females and 48.4% were males, 29.7% had diabetes, 51.3% had hypertension and 19.0% had both diseases. Among all, 84.2% reported dissatisfaction with the current healthcare system, 31.6% reported changing their physician mainly because of unaffordable consultation fees (66%) or immigration of the physician (32%). Of those with hypertension and/or diabetes, less than 20% reported finding all their prescribed medications and 47% either modified or discontinued their treatment without seeking medical advice. In case of drug shortage, patients relied on stocked reserves (26%), alternative/generic medications (10%) and external sources for medication procurement such as relatives living abroad (41.7%), outsourcing suppliers (19.9%), dispensaries (19.6%) and NGOs (20.3%). All participants reported a high stress level (5.03/7) with a mean total DASS-21 score of 38.7 ± 35.8 that were attributed to August 4th Beirut port explosion (81.0%), global pandemic (81%), unstable political conditions (90.5%), economic crisis (96.8%), medication shortage (91.8%) and inability to access healthcare (74.1%). Higher sub-scores for anxiety, depression and total stress were insignificantly noted in participants with both hypertension and diabetes (p > 0.05). Conclusion Our findings explore how the economic crisis has taken its toll on almost all aspects of healthcare in a sample of patients with diabetes and hypertension in Lebanon. The drug shortage as well as disruptions in affordable healthcare access imposed several barriers to adequate adherence to treatment regimens and acted as important mental health stressors.

Deep learning has significantly transformed face recognition, enabling the deployment of large-scale, state-of-the-art solutions worldwide. However, the widespread adoption of deep neural networks (DNNs) and the rise of Machine Learning as a Service emphasize the need for secure DNNs. This paper revisits the face recognition threat model in the context of DNN ubiquity and the common practice of outsourcing their training and hosting to third-parties. Here, we identify backdoor attacks as a significant threat to modern DNN-based face recognition systems (FRS). Backdoor attacks involve an attacker manipulating a DNN’s training or deployment, injecting it with a stealthy and malicious behavior. Once the DNN has entered its inference stage, the attacker may activate the backdoor and compromise the DNN’s intended functionality. Given the critical nature of this threat to DNN-based FRS, our paper comprehensively surveys the literature of backdoor attacks and defenses previously demonstrated on FRS DNNs. As a last point, we highlight potential vulnerabilities and unexplored areas in FRS security.

Abstract Background A high neutrophil-lymphocyte ratio (NLR) may be associated with worse survival in esophageal cancer (EC). Our aims were to describe the demographic and clinical data of EC in a tertiary referral center in Lebanon and to determine the prognostic value of NLR. Methods A retrospective cohort study based on chart review of patients diagnosed with EC was conducted at the American University of Beirut Medical Center (AUBMC). The demographic characteristics, clinical presentation and outcomes were described and compared between squamous cell carcinomas (ESCC) and adenocarcinomas (EAC). Data about esophageal cancer incidence were obtained from the National Cancer Registry, the Ministry of Public Health and GLOBOCAN 2020. Cox regression analysis was performed to determine whether the NLR is an independent predictor of survival, using variables based on clinical knowledge and previously established data. Results 110 patients were diagnosed with EC, which was the least common among other gastrointestinal malignancies. Our follow up rates reached 86.4%. The median survival was 9 months (IQR 3–25.5.) and was comparable between ESCC (median of 7 months, IQR 2–25) and EAC (median of 9 months, IQR 3–26.3), p = 0.803. Advanced stage was associated with a worse prognosis (p = 0.037). The mean NLR(±SD) was 5.20 ± 6.8, with no significant difference between EAC and ESCC (4.5 ± 3.4 vs. 5.9 ± 9.2, p = 0.420) or between early or advanced stages (5.4 ± 8.1 vs. 4.7 ± 6.8, p = 0.732). The area under the curve for the NLR was 0.560 (95% CI: 0.374–0.746, p = 0.488). After adjusting for age, gender, TNM staging and grading, cox regression analysis showed that an increased NLR was a significant predictor of mortality, with an adjusted hazard ratio of 1.095 (p = 0.011). Conclusion EC is quite uncommon in Lebanon despite a high prevalence of smoking and obesity. Advanced stage and high NLR were associated with a negative prognostic value.

Abstract Introduction Some worry that physician practices acquired by private equity may increase the use of services to maximize revenue. We assessed the effects of private equity acquisition on spending, use of treatment, and diagnostic testing in men with prostate cancer. Methods We used a 20% sample of national Medicare claims to perform a retrospective cohort study of men with prostate cancer diagnosed from 2014 through 2019. The primary outcome was prostate cancer spending in the first 12 months after diagnosis. Secondary outcomes included the use of treatment and a composite measure of diagnostic testing (e.g., imaging, genomics) in the first 12 months after diagnosis. Multilevel modeling was used to adjust for differences in patient and market characteristics. The effect of practice acquisition on each outcome was assessed using a difference‐in‐differences design. Results There were 409 and 4021 men with prostate cancer managed by urologists in acquired and nonacquired practices, respectively. After acquisition, prostate cancer spending was comparable between acquired and nonacquired practices (difference‐in‐differences estimate $1182, p = 0.36). Acquisition did not affect the use of treatment (difference‐in‐differences estimate 3.7%, p = 0.30) or the use of diagnostic testing in men who were treated (difference‐in‐differences −5.5%, p = 0.12) and those managed conservatively (difference‐in‐differences −2.0%, p = 0.82). Conclusions In the year following acquisition of urology practices, private equity did not increase prostate cancer spending, the use of treatment or diagnostic testing in men with prostate cancer. Future work should evaluate the effects of private equity acquisition on practice patterns and quality over a longer time horizon.

Seawater intrusion (SWI) stands as a significant challenge impacting coastal aquifers worldwide. The emergence of SWI is a natural phenomenon owing to the density difference between seawater and freshwater. Even without any pumping, the seawater naturally advances inland until a hydrostatic equilibrium between the two water sources is reached. However, human interventions, such as excessive groundwater extraction, coastal developments, and land use as well as climate change intensify the SWI predicament. Efficient solutions to counteract the SWI problem involve the implementation of hydraulic barriers. By employing the Henry problem as a benchmark, the Finite Element Simulator (FEFLOW), which is a numerical modeling software, was used for simulating the flow and transport processes. An integrated FEFLOW-Python code was developed to optimize hydraulic barriers for mitigating SWI. The methodology aims to achieve the maximum possible reduction in SWI by iteratively adjusting the locations and rates of pumping and injection wells. Unlike other investigations, this study explores the utilization of negative SWI barriers to extract brackish water from the dispersion zone and potentially offer a cost-effective alternative water source for desalination plants’ intakes. For the Henry Problem, to maximize the reduction in of SWI, brackish water extraction wells should be situated near the center-bottom of the intrusion zone, with a pumping rate of 2.5 m3/day. For injection wells, the optimal location varies depending on the injection rate (I). Achieving the highest retardation (61%) occurs when the injection rate is 1 m3/day, positioned at the aquifer’s bottom and close to the coastal boundary. However, for injection rates below 0.7 m3/day, the injection well’s optimal location shifts towards the seawater intrusion toe. This study presents a novel approach by establishing explicit correlations for optimizing hydraulic barriers to effectively manage and mitigate SWI.

Background and aim: Melanoma is a fatal form of skin cancer that carries a grave prognosis if the cancer cells spread and form metastases. The Kynurenine (Kyn) pathway is activated by the enzyme indoleamine 2,3-dioxygenase 1 (IDO-1) and has been shown to have a role in tumour progression. We have previously shown that interferon-γ (IFN-γ) acts as an inducer of tryptophan (Trp) degradation to Kyn in keratinocytes of the basal layer in a 3D epidermis model. Before extending our reconstructed human epidermis model to not only contain keratinocytes but also fibroblasts and melanocytes/melanoma cells, we have in this study set out to investigate possible differences between primary adult melanocytes and six melanoma cell lines regarding the expression of the immune checkpoint inhibitors IDO-1 and programmed death ligand 1 (PD-L1) together with Kyn production. Methods: The melanocytes and melanoma cells were stimulated with 1–20 ng/ml of IFN-γ and the levels of Trp to Kyn degradation were monitored with high-performance liquid chromatography (HPLC). To analyze the viability of the cell types after IFN-γ treatment, an MTT assay was performed. mRNA quantity of IDO-1, PD-L1 and IFN-γ receptor (IFN-GR1) was analyzed with qPCR. Results: After 24 h, only the metastatic cell line WM-266-4 was affected by all concentrations of IFN-γ, whereas at 48 h, the higher IFN-γ concentrations gave a more pronounced effect on the viability in all cell types. Trp was detected at various levels in the culture medium from all cell types before and after IFN-γ treatment. The degradation to Kyn was detected in primary melanocytes, Mel Juso, and Mel Ho cell lines after 24 h of treatment and low levels of IFN-γ. However, the higher concentration of IFN-γ, 20 ng/ml, induced Kyn to various degrees in all cell types after 24 h. The change in mRNA quantity of IDO-1 and PD-L1 was similar in all cell types. Conclusion: To conclude, no significant difference in upregulation of the immune checkpoint inhibitors PD-L1 and IDO-1 was seen between primary tumour and metastatic melanoma. IFN-γ stimulation of melanocytes and different stages of melanoma cell lines resulted in an increased Kyn/Trp ratio in the more aggressive melanoma cells when a high concentration was used (20 ng/ml) but when a lower concentration of IFN-γ (5 ng/ml) was used an increased Kyn/Trp ratio were detected in media from primary melanocytes and early-stage melanoma.